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Much the same can be said of the introduction of the market in health, which has so far produced somewhat similar results. A joint investigation in 2007 by the Healthcare Commission and the Audit Commission found that those parts of the NHS that had adopted market style reforms most keenly did not perform significantly better than those slower to change. The NHS improved, thanks to record growth in spending backed by targets to reduce waiting times. These were,

Interestingly enough, one of the report’s conclusions was that one of the drivers behind improving services was not so much patient choice itself but the fear of the impact of patient choice, which was effecting a change in attitude among providers. The same conclusion was picked up by the King’s Fund, which suggested that some American studies had found that improvement in quality is driven not by patients actually switching providers but by the impact on hospital managers concerned about the public image of their organisation. The King’s Fund briefing states:

“The implication for the NHS is that choice may have an impact even if few patients actually use the information to switch hospitals in practice”.

It is too early for any evaluation of these choice effects on equity but the London choice pilots in the NHS indicated that there was no difference in the take-up of choice by socio-economic groups. On the other hand, each patient was supported by a “choice adviser” who provided individualised support, as has been suggested for disadvantaged families with regard to schools.

I come back to the Isaiah Berlin quotation and the trade-offs between choice, equality and other values. As a Liberal Democrat, I hold liberty, and all that it stands for in terms of freedom to choose one’s own destiny, very dear. However, I must recognise that adherence is not unlimited and that there are trade-offs to be made with other values. Evidence suggests—I have referred to that from education and health—that we cannot have total freedom of choice without exacerbating inequalities. I suggest that equality in itself has value. Britain is today a very unequal society experiencing its most unequal distribution of income since the mid-20th century. Social factors are linked to income and wealth factors. There is a good deal of evidence from the United States that those states that have greater equality in terms of the distribution of income also have not only lower morbidity rates—we

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see this in the 1980 Black report on the National Health Service—but lower rates of violence, hooliganism and anti-social behaviour. Those factors are all linked to inequalities in income. Distrust of others is also linked to inequality of income.

Tawney says of inequality that,

I suppose today we would call an open road a level playing field but I much prefer “an open road”—

My thesis is that liberty, the freedom to choose and equality are not a zero sum game. The ability to make use of and enjoy opportunities in a democratic society will be enhanced, not curtailed, by a fairer distribution of income and wealth in our society.

3.34 pm

Lord Krebs: My Lords, I thank my noble friend Lady O’Neill for introducing such an important topic for debate and declare an interest as a co-author of a report for the Nuffield Council on Bioethics on the ethics of public health. It is on health that I wish to focus my attention in the next few minutes.

Let me start by giving the good news and the bad news. The good news is that people’s health in this country has improved dramatically over the past century. A boy born today has a life expectancy of about 76 years; a boy born in 1901 had a life expectancy of a mere 45 years. This increase continues today. According to one estimate, expectancy of life is increasing at a rate equivalent to 12 minutes per hour, so even by sitting and listening to my speech, your life expectancy will increase by two minutes.

Now for the bad news; there are still great inequalities in health in this country. The World Health Organisation figures shows that in Glasgow, a boy growing up in the deprived suburb of Calton can expect to live for only 54 years, which is a staggering 28 years less than a boy born just a few miles away in the affluent suburb of Lenzie. We would surely agree that this is unacceptable.

Why has life expectancy increased, and why are there still such large inequalities? I am sure that noble Lords know the answer. Our life expectancy has increased in part because of vastly improved medical treatment once we are sick, and partly because of a wide range of public health measures to prevent us getting ill in the first place. These include vaccination against disease, improvements in our nutrition, the air we breathe, the water we drink, and the general conditions in which we live. The disparities in health that remain are also a result of many factors, but they are generally associated with deprivation, low social class, the certain kinds of employment, or lack of employment, living conditions and lifestyle.

To take just one example of a disparity in risk, in 2005 in England, 29 per cent of manual workers smoked, compared with 19 per cent of those in non-manual groups. Since half of all smokers die prematurely, this difference among social classes—there are also big differences among ethnic groups—is a significant contributor to health inequalities.

The political philosopher Ronald Dworkin wrote:

“No government is legitimate that does not show equal concern and respect for the fate of all those citizens over whom it claims dominion”.



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I hope that all noble Lords would agree with this sentiment. The Department of Health certainly does. I quote from its website—although I bear no responsibility for the poor English:

“Health inequalities are unacceptable. They start early in life and persist not only into old age but subsequent generations. Tackling health inequalities is a top priority for this Government, and it is focused on narrowing the health gap between disadvantaged groups, communities and the rest of the country”—

whatever that might mean—

How can the Government reduce health inequalities, particularly inequalities in the burden of chronic diseases that are now the major causes of premature death, such as heart disease, cancer, and type 2 diabetes?

The particular challenge of these diseases is that they are so-called lifestyle diseases. Factors such as diet, exercise, smoking and excessive drinking contribute substantially to variation in risk. Any kind of intervention by the Government into people’s lifestyle is almost certain to be branded as the nanny state at work. Here, the familiar trade-off—the noble Baroness, Lady Sharp, referred to it—is between, on the one hand, leaving each of us free to lead the life we wish and, on the other, the duty of the state to reduce inequalities and protect the most vulnerable in society.

That brings me to choice. As has been said, all political parties favour policies to reduce inequalities in health that are based on information and choice. Choice is an attractive policy option, partly because it is the leitmotif of our consumer society and therefore fits with people’s expectations and partly because it is not intrusive. “Give people the information and empower them to choose” sounds very plausible and acceptable.

I argue that much of the choice that we are offered is illusory and, more importantly, that choice alone is most unlikely to succeed in reducing health inequalities. Why do I say that choice is illusory? Because many of the choices that we make, for instance, the kind of food we buy in the supermarket, or whether we cycle to work for the exercise, are constrained by the decisions of others; in these examples, retailers and urban planners.

Their decisions shape and limit the choices and they are motivated by factors such as profit, other than improving our health and reducing inequalities. In fact, the very opposite is the case: those who construct and constrain our environment have conspired to create what the experts call an obesogenic environment, in which the easy choices lead to ill health, rather than good health.

Even with the choices you have, how do you know which are the “right” ones. In his book, The Paradox of Choice, Barry Schwartz vividly describes the impossibility of choosing between the 230 different kinds of soup, 275 varieties of cereal and 15 varieties extra virgin olive oils in his local supermarket. There is even a further problem with choice. It is a fundamental feature of our nature that we prefer options that satisfy our short-term needs, rather than our long-term benefit. Psychologists refer to this as “failure to delay gratification”, which we heard about this morning in the debate on climate change.



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Why do I say that choice will not reduce health inequalities? The problem with information and choice is that the money, the opportunities, the will, and the skill to respond to choice tend to be highest among those who are already doing well, and lowest among those most in need of help. A recent study in the Journal of Health Services Research & Policy makes the point. It states:

“Better educated populations make greater use of information and are more likely to exercise choice in health care”.

So is a more interventionist stance necessary and justified? The Government’s Foresight report on obesity not only documents the rapid rise incidence of obesity, and its huge social-class difference—for instance, the prevalence of obesity is 18 per cent among men in social class 1 and 28 per cent for men in class 5—but the report considers a wide range of policy options and concludes by saying that:

“Our evidence shows that a substantial degree of intervention is required”.

Does the Minister agree with this conclusion? Does she accept that while exhorting people to eat healthily and exercise more, and putting nutrition labels on food, may have some benefit, it is not likely to succeed in reducing health inequalities resulting from obesity? If the Government are serious about achieving their objectives stated on the Department of Health website, they will have to be bolder and, perhaps, more interventionist. Choice may be the easy option, but it will not work on its own.

I end on two points. Where the Government rely on information and choice, they must ensure, if necessary by regulating the groups and interests that shape our choices in the way that I have described, that it is easy for people to choose the options that will lead to better health—nudging in the terminology of Thaler and Sunstein. Secondly, if Government are to fully exercise their stewardship responsibilities in reducing health inequalities, they must be prepared to go beyond choice.

The approach of successive Governments to tobacco is a possible model. A combination of education, legislation and taxation has reduced the overall prevalence of smoking from more than 75 per cent of the population to less than 25 per cent today, although substantial inequalities remain, as I have said. The current Health Bill proposes new and welcome measures to further restrict the ways in which the tobacco industry is able market and sell cigarettes. If these measures are implemented, they will help to reduce inequalities in health.

Let us hope that in the future, Governments will have the courage to tackle other health inequalities with equal determination.

3.44 pm

The Lord Bishop of Chester: My Lords, I shall attempt a synthesis between the position of the noble Lord, Lord Patten, and that of the noble Lord, Lord Krebs. I am not sure how successful I shall be.

Choice is potentially a good thing. Freedom, which choice seeks to express, is in some sense central to authentic human experience. It has certainly been part of the rhetoric and inspiration of the British national

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character and history. One thinks of Churchill’s most inspiring rhetoric, contrasting freedom and tyranny—although the 20th century also demonstrated how freedom that exists simply out of its own strength and for its own purpose can become its own tyranny. One thinks of Sartre’s epithet: “Hell is other people”.

The problem can be put this way. Any society or system that bases itself on freedom and choice without restraint, moderation and, to use an in-vogue word, regulation tends to produce an exaggerated outcome in winners and losers. In society as a whole, the losers can easily slip into becoming an underclass, where poverty and underachievement become endemic, as is the case in terms of health in parts of Glasgow and elsewhere. A symptom of this is a larger-than-average prison population.

If the United States comes immediately to mind, there is a great deal about British history since 1979 that exhibits similar strains and imbalances, with an inexorably rising prison population here, too, and ingrained poverty among certain sections of our people. With that goes the well rehearsed problem of underachievement in the lower educational reaches of our schools. There is more than one way in which a society can sleepwalk into segregation. Arguably, we see the same dynamic at work today in the former Soviet Union, especially in Russia, with the extraordinary, and extraordinarily rapid, emergence of a super-rich elite. I cannot believe that this will be to the long-term benefit of Russian society.

The question that I have puzzled over as I have thought about the topic for this debate is how a society can promote freedom and choice yet avoid the worst outcomes which produce exaggerated winners and endemic entrenched losers. In the year when we especially recall Charles Darwin, I shall try to illustrate briefly how choice emerges in the process of evolution. Scientists tell us that the universe came into existence about 13 billion years ago. For most of those billions of years, no life had yet emerged, but then there was no death either. Death comes as a consequence of the emergence of life. As evolution advanced and plant life came about, so came the possibility of diseases or the deformation of plants, with one organism impairing another. Further up the evolutionary tree came animals, which had a greater sense of choice and meaning—the ability to move around their environment—but then one animal could prey on another. The arrival of human beings also brought the ability to relate to eternal, transcendent values of truth, beauty, justice, love and so forth. However, along with that came the emergence of moral evil. Nature may be red in tooth and claw but in the animal world you do not get the equivalent of a Hitler or a Pol Pot.

The point is that, as the freedom of creation develops, choice emerges, and it brings both the flowering of true humanity and a corresponding threat. So it is that choice and freedom tend to generate winners and losers, and a corresponding increase in inequality. To some extent, that will be inevitable in any society, but I think that society needs to seek to set certain limits to it in one way or another.



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This, I believe, has been a major part of the story of Britain, especially over the past 30 years. I do not argue that this has been altogether bad. Indeed, I think that there have been many positive outcomes during this period in terms of choice, opportunity and the benefits of economic liberalism. In relation to the last, there has also been an underlying instability, which is being cruelly exposed in the current banking crisis.

With freedom must always come responsibility and an obligation towards the common good of wider society. Archbishop William Temple put it this way:

“Concentration on acts of choice as the proper locus of freedom ... is a blunder. Freedom is not absence of determination; it is spiritual determination ... by what is intrinsically good”.

This is an ideal, of course, and in practice both individuals and society as a whole will fall short, but all the more reason for seeking active commitments to moderate or avoid the inequalities that too narrow a focus on choice will tend to generate. These need to be the commitments of government, individuals and the intermediate institutions in society alike.

I follow others who have contributed to the debate by reflecting on what this might imply in the area where choice has been given so much prominence in recent decades: education. There has often been official puzzlement at the stubbornly high and socially unacceptable underachievement in our secondary schools, particularly by those in the lowest quartile of achievement, despite 20 years of being given a priority by government in both planning and the allocation of funds. The built environment of schools has seen a significant and welcome transformation, but that has not been matched by improvements in the achievement of those at the lower end of the scale in particular.

Choice operates in the state system by reinforcing the differences between good and bad schools, or those that are perceived by parents to be good and bad. The academy programme has been part of the response, by rebuilding or replacing schools in underperforming areas with new schools endowed, at least in theory, with new freedoms. In many ways I regard the academy programme as an imaginative response to the educational challenges in more deprived areas, but one consequence has been further to disadvantage non-academies in neighbouring catchment areas, which are often themselves struggling somewhat. I expect that the academy programme will achieve its aims only when all or most schools are organised along those lines and other policies are in place to support the weakest schools and the poorest areas to take account of their intrinsic tendency to fall down the scale where the natural forces of parental choice are permitted to operate—and they will tend to operate whatever restrictions are placed on them.

Of course, although this is rarely introduced into our debates, choice operates in another way between schools, to benefit some and disadvantage others. I refer to the choice of around 8 per cent of the wealthiest parents to send their children to private schools. These schools are usually academically selective, which unavoidably makes them socially selective, and the resources spent per pupil are typically higher than in the state sector. We ought to ask much more searching

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questions about how society can ameliorate those inequalities that so distort school-age education in our country. I say that as a parent who has sent a child with special needs to private school, because it is naturally the instinct of every parent to do the best for their child. I pay tribute to the excellence exhibited in many private schools and to the academy programme, which is an attempt to emulate them.

The educational playing field needs undergirding policies that aim at least to promote levelling out, including a clear plan to match in state schools in this country the spending per pupil in private schools. Interestingly, higher education arguably presents a better picture. Students attend by choice and the Government have a good policy to increase and widen participation. The universities, unlike state schools, are independent institutions, so to achieve their aims the Government have operated through quite a sophisticated mechanism of regulation for home undergraduates—HEFCE, which is, theoretically at least, at arm’s length from government—allocating funded places with some care and moving to support weaker institutions, despite their formal and, indeed, actual independence.

I hear suggestions that new elements of choice may soon be injected into this sector by lifting the fee cap and perhaps by deregulating a proportion of home undergraduate places. Those who have the responsibility for these matters should think long and hard before moving in those directions, with due attention to the law of unintended consequences.

In summary, choice and equality of outcome are inevitably in tension, but it is possible for a society both to respect choice and to develop ways of operating policies and social norms that seem to ameliorate the worst outcomes of inequality.

3.54 pm

Lord Northbourne: My Lords, I thank my noble for friend for introducing this thoughtful debate and I congratulate my noble friends on the Cross Benches on such a good turnout.

I shall look at the impact of choice and equality in the context of families. The tension between choice and equality is strong for various reasons, but particularly because it tends to be the parents who make the choices and the children who suffer from the inequalities that may arise. In saying that, I should add that there are 11 million children in this country, which is a substantial constituency. My noble friend has already spoken about how parents can entrench inequality by their choice of schools. I shall not follow that train of thought because I want to draw attention to another kind of parental choice, which arguably is even more important. It concerns the kind and quality of family life that parents choose to give their child.

In today’s society, the most important influences on children’s chances in life are likely to be the quality of the family life that they enjoy and their relationship with their parents. We all know that young children need to have a secure attachment to a mother or surrogate mother whom they love. They need to feel safe, to be talked to, to be played with, to be stimulated and to be encouraged. The family support that children

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get before entering school is a major factor in their ability to integrate into school and to learn. Even in full-time schooling, children spend less than 30 per cent of their waking time in school. That means that 70 per cent of their waking time is spent with or under the influence of their family, so it is their life in their family that should give them the ability and self-confidence to integrate into school, understand what is going on, participate and learn. It should develop their self-confidence and age-appropriate social and emotional skills. Crucially, it should give them the ability and confidence to communicate verbally before they get to school and with adults and other children once they arrive. Without those skills, children arrive in school already at a disadvantage.

A government-sponsored report by Charles Desforges confirms everything that I am saying. In 2005, he demonstrated that a substantial body of research shows the important links between the quality of children’s family life and their success in school and therefore, arguably, in later life. Luckily, most parents, most of the time, give their children the family life that they need, but some do not. We need to explore the ways and the reasons why some children are not getting the parental support and family life that they need.

Some of the reasons are beyond the control of parents. We all know about poor mental health, drug and alcohol abuse, domestic violence, poor housing, single parenthood and poverty. It must be a priority for any responsible Government to do their best to address these matters and help parents and families that have these problems and to do so even more effectively than the Government are at present achieving.

However, when all those factors have been discounted, there remain many cases where parental choice may be a major contributory factor in denying a child the quality of family life that he or she needs. I shall give three examples: teenage pregnancy; a father walking away from his young child in order to form another family; and a mother deciding to have several children by different fathers and then bringing them up in a household where her partner is not the father of any of them. Those are three examples of the enormous number of ways in which parents can affect their child’s future and ability to achieve equality of outcomes.


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